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Francis JH, Canestraro J, Abramson DH, Barker CA, Shoushtari AN. Combination intravitreous melphalan and bevacizumb for cutaneous metastatic melanoma to the vitreous and retina. Am J Ophthalmol Case Rep 2022; 26:101519. [PMID: 35464680 PMCID: PMC9020100 DOI: 10.1016/j.ajoc.2022.101519] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 01/25/2022] [Accepted: 04/03/2022] [Indexed: 11/25/2022] Open
Abstract
Purpose Cutaneous melanoma metastatic to the vitreous/retina is rare but increasingly common. Due to the potential of recurrent disease with current treatment options and the propensity for these eyes to develop neovascularization, these eyes can pose a treatment challenge and novel management strategies are needed. This case series explores the use of combination, sequential intravitreous melphalan and bevacizumab. Observation Two eyes of two patients with cutaneous melanoma metastatic to the vitreoretina were eye treated with combination intravitreous melphalan (10-30 mcg) and bevacizumab (1.25 mg) given sequentially during the same office visit, at monthly intervals. Both cases had control of disease at 7- and 12-months follow up. Furthermore, treatment reversed neovascular glaucoma and dramatically improved vision in the eye of one patient; and stabilized vision without the development of neovascularization in the eye of the other patient. There were no ocular adverse events noted in either eye. Conclusions and Importance Combination, sequential intravitreous melphalan and bevacizumab is well-tolerated and an attractive approach for treating eyes with intraocular metastatic melanoma. Cutaneous melanoma metastatic to the vitreous/retina is rare but increasingly common. Combination intravitreous melphalan/bevacizumab is an option for these eyes. This can control disease and reverse/prevent the characteristic neovascularization.
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Teras J, Carr MJ, Zager JS, Kroon HM. Molecular Aspects of the Isolated Limb Infusion Procedure. Biomedicines 2021; 9:biomedicines9020163. [PMID: 33562337 PMCID: PMC7915579 DOI: 10.3390/biomedicines9020163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 01/30/2021] [Accepted: 01/31/2021] [Indexed: 01/19/2023] Open
Abstract
For decades, isolated limb infusion (ILI) and hyperthermic isolated limb perfusion (HILP) have been used to treat melanoma in-transit metastases and unresectable sarcoma confined to the limb utilizing the effect of loco-regional high-dose chemotherapy to the isolated limb. Both procedures are able to provide high response rates in patients with numerous or bulky lesions in whom other loco-regional treatments are becoming ineffective. In comparison to systemic therapies, on the other hand, ILI and HILP have the advantage of not being associated with systemic side-effects. Although in principle ILI and HILP are similar procedures, ILI is technically simpler to perform and differs from HILP in that it takes advantage of the hypoxic and acidotic environment that develops in the isolated limb, potentiating anti-tumour activity of the cytotoxic agents melphalan +/− actinomycin-D. Due to its simplicity, ILI can be used in both preclinical and clinical studies to test new cytotoxic regimens and combinations with the aim to overcome tumour resistance. In the future, administration of cytotoxic agents by ILI, in combination with systemic treatments such as BRAF/MEK/KIT inhibitors, immunotherapy (CTLA-4 blockade), and/or programmed death (PD-1) pathway inhibitors, has the potential to improve responses further by inducing increased tumour cell death while limiting the ability of the tumour to suppress the immune response.
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Affiliation(s)
- Jüri Teras
- Department of Surgical Oncology, North Estonia Medical Centre Foundation, 13419 Tallinn, Estonia;
- Tallinn University of Technology, 12616 Tallinn, Estonia
| | - Michael J. Carr
- Department of Cutaneous Oncology, Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA; (M.J.C.); (J.S.Z.)
| | - Jonathan S. Zager
- Department of Cutaneous Oncology, Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA; (M.J.C.); (J.S.Z.)
- Department of Oncologic Sciences, University of South Florida Morsani College of Medicine, Tampa, FL 33612, USA
| | - Hidde M. Kroon
- Department of Surgery, Royal Adelaide Hospital, Adelaide, SA 5000, Australia
- Faculty of Health and Medical Sciences, School of Medicine, University of Adelaide, Adelaide, SA 5000, Australia
- Correspondence: ; Tel.: +61-8-7074-2163
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Martin-Tellez KS, van Houdt WJ, van Coevorden F, Colombo C, Fiore M. Isolated limb perfusion for soft tissue sarcoma: Current practices and future directions. A survey of experts and a review of literature. Cancer Treat Rev 2020; 88:102058. [PMID: 32619864 DOI: 10.1016/j.ctrv.2020.102058] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 06/11/2020] [Indexed: 12/15/2022]
Abstract
Soft tissue sarcomas constitute 1% of adult malignant tumors. They are a heterogeneous group of more than 50 different histologic types. Isolated limb perfusion is an established treatment strategy for locally advanced sarcomas. Since its adoption for sarcomas in 1992, after the addition of TNFα, few modifications have been done and although indications for the procedure are essentially the same across centers, technical details vary widely. The procedures mainly involves a 60 min perfusion with melphalan and TNFα under mild hyperthermia, achieving a limb preservation rate of 72-96%; with an overall response rates from 72 to 82.5% and an acceptable toxicity according to the Wieberdink scale. The local failure rate is 27% after a median follow up of 14-31 months compared to 40% of distant recurrences after a follow up of 12-22 months. Currently there is no consensus regarding the benefit of ILP per histotype, and the value of addition of radiotherapy or systemic treatment. Further developments towards individualized treatments will provide a better understanding of the population that can derive maximum benefit of ILP with the least morbidity.
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Affiliation(s)
- K S Martin-Tellez
- Fellow of the European School of Soft Tissue Sarcoma, Department of Surgical Oncology, The American British Cowdray Medical Center ABC, Mexico city, Mexico.
| | - W J van Houdt
- Sarcoma Unit, Department of Surgical Oncology, The Netherlands Cancer Institute Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - F van Coevorden
- Sarcoma Unit, Department of Surgical Oncology, The Netherlands Cancer Institute Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - C Colombo
- Sarcoma Unit, Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | - M Fiore
- Sarcoma Unit, Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy
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Enhancement of melphalan activity by buthionine sulfoximine and electroporation in melanoma cells. Anticancer Drugs 2015; 26:284-92. [PMID: 25514113 DOI: 10.1097/cad.0000000000000192] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Melphalan represents the reference drug for locoregional chemotherapy of melanoma; nevertheless, treatment failure may occur because of resistance to chemotherapy. Refractory melanoma cells show either an increased capability of drug inactivation, which is known to be associated with elevated intracellular levels of glutathione (GSH), or a decreased melphalan uptake. The aim of this study was to explore a biochemical and a biophysical strategy, and their combination, to overcome melphalan resistance in melanoma cells. The biochemical strategy was based on the treatment of melanoma cells with DL-buthionine (S,R)-sulfoximine (BSO) to deplete the GSH levels, thus reducing melphalan inactivation. In the biophysical strategy, cell membrane electroporation was used to increase melphalan uptake. The SK-MEL 28-resistant human melanoma cell line was pretreated with 50 μmol/l BSO for 24 h and then treated with increasing melphalan doses, with or without electroporation. Spectrophotometric quantification of cell viability was used to determine melphalan cytotoxicity. Intracellular total GSH was measured using a kinetic enzymatic assay. BSO induced 3.50-fold GSH depletion in untreated cells and a similar reduction was also maintained in melphalan-treated cells. BSO pretreatment produced a 2.46-fold increase in melphalan cytotoxicity. Electroporation increased melphalan cytotoxicity 1.42-fold. The combination of both BSO pretreatment with melphalan plus electroporation led to a 4.40-fold increase in melphalan cytotoxicity compared with melphalan alone. Pretreatment with BSO and cell membrane permeabilization by electroporation enhanced the cytotoxic activity of melphalan in melanoma cells. Their rational combination deserves further investigation and may improve the efficacy of locoregional chemotherapy of melanoma.
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Rashid OM, Sloot S, Zager JS. Regional therapy in metastatic melanoma: an update on minimally invasive intraarterial isolated limb infusion and percutaneous hepatic perfusion. Expert Opin Drug Metab Toxicol 2014; 10:1355-64. [DOI: 10.1517/17425255.2014.951330] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Kim M, Blum AB, Haslinger ML, Donahue MJ, Fisher DT, Skitzki JJ, Park IY. Quinacrine for extremity melanoma in a mouse model of isolated limb perfusion (ILP). Surg Today 2014; 45:355-62. [PMID: 24998594 DOI: 10.1007/s00595-014-0952-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Accepted: 02/03/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE Quinacrine is a relatively non-toxic drug, once given almost exclusively for malaria. However, recent studies show that quinacrine can suppress nuclear factor-κB (NF-κB), and activate p53 signaling. We investigated the anti-cancer effect of quinacrine, using a novel mouse model of isolated limb perfusion (ILP) for extremity melanoma. METHOD Female C57BL/6 mice (22-25 g) were injected with B16 melanoma cells (1 × 10(5)) subcutaneously in the distal thigh. After 7 days of tumor establishment, mice were perfused with either PBS, melphalan (90 µg), or quinacrine (3.5 and 4.5 mg) through the superficial femoral artery for 30 min at either 37 or 42 °C in a non-oxygenated circuit. We analyzed morbidity, toxicity, tumor apoptosis, and responses. RESULTS Melanoma cell death following in vitro exposure to quinacrine was dose and time dependent. A significant decrease in mean tumor volume was observed after perfusion with low-dose and high-dose quinacrine (both P = 0.002) at 37 °C as well as after perfusion with low-dose quinacrine (P = 0.0008) at 42 °C. CONCLUSION Quinacrine has demonstrable efficacy against melanoma cells in vitro and in a clinically relevant model of ILP. Further studies to evaluate the optimal conditions for quinacrine usage are warranted.
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Affiliation(s)
- Minhyung Kim
- Department of Surgical Oncology, Roswell Park Cancer Institute, Buffalo, NY, USA,
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Wouters J, Stas M, Govaere O, Van den Eynde K, Vankelecom H, van den Oord JJ. Gene expression changes in melanoma metastases in response to high-dose chemotherapy during isolated limb perfusion. Pigment Cell Melanoma Res 2012; 25:454-65. [PMID: 22486811 DOI: 10.1111/j.1755-148x.2012.01004.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Despite recent advances in melanoma therapy, disseminated melanoma still lacks effective treatment, and recurrence of the tumor frequently occurs, even after high-dose chemotherapy. The mechanisms responsible for this chemoresistance or for the formation of new relapses remain poorly understood. Using a human 'model', in which the isolated limb is perfused with high doses of the chemotherapeutic melphalan (ILP), we identified a five-gene set (ATF3, CYR61, IER5, IL6, and PTGS2) of stress-induced genes that was consistently upregulated after ILP in all in-transit metastatic melanoma samples as well as in three melphalan-treated melanoma cell lines. Early post-ILP relapses retained these elevated expressions, whereas the expression of these genes returned to their original levels in late post-ILP recurrences. In addition, we identified upregulation of these genes in the A375 cell line's side population (SP) and melanospheres, established methods to enrich for candidate cancer stem cells (CSCs), which are considered chemoresistant and tumorigenic, and thus proposed to be responsible for tumor relapse. Our data identify an immediate and short-term upregulation of early stress-responsive genes that are potentially linked to chemoresistance and CSCs.
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Affiliation(s)
- Jasper Wouters
- Translational Cell & Tissue Research, Department of Imaging and Pathology, KU Leuven, Leuven, Belgium.
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Huismans AM, Kroon HM, Haydu LE, Kam PCA, Thompson JF. Is Melphalan Dose Adjustment According to Ideal Body Weight Useful in Isolated Limb Infusion for Melanoma? Ann Surg Oncol 2012; 19:3050-6. [DOI: 10.1245/s10434-012-2316-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2011] [Indexed: 11/18/2022]
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Han D, Beasley GM, Tyler DS, Zager JS. Minimally invasive intra-arterial regional therapy for metastatic melanoma: isolated limb infusion and percutaneous hepatic perfusion. Expert Opin Drug Metab Toxicol 2011; 7:1383-94. [PMID: 21978383 PMCID: PMC4630979 DOI: 10.1517/17425255.2011.609555] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION In-transit melanoma or melanoma presenting as unresectable liver metastases are clinical situations with limited therapeutic options. Regional intra-arterial therapies provide efficacious treatment alternatives for these patients. Through surgical techniques of vascular isolation, regional therapies deliver high-dose chemotherapy to tumor cells while minimizing systemic exposure. However, percutaneous techniques such as isolated limb infusion (ILI) and percutaneous hepatic perfusion (PHP) have been developed, which provide a minimally invasive means of obtaining vascular isolation of target organs. AREAS COVERED Areas covered in this review include the techniques of ILI and PHP, the chemotherapeutic agents utilized during these regional therapies and the clinical responses seen after ILI and PHP. The pharmacokinetics of regional chemotherapy utilized during ILI and PHP is also reviewed with an additional focus on novel ways to optimize drug delivery to improve response rates and attempts to define the potential systemic manifestations of regional therapeutics. EXPERT OPINION Unresectable hepatic and limb in-transit metastases from melanoma are very difficult to treat. Systemic chemotherapy has largely been ineffective. Both the minimally invasive, percutaneous techniques of ILI and PHP are excellent methods used to deliver extremely high-dose chemotherapy regionally to patients harboring metastatic melanoma confined to an extremity or liver, respectively. Studies, from prospectively maintained databases as well as Phase II and III trials, have shown the great efficacy of these techniques.
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Affiliation(s)
- Dale Han
- Surgical Oncology Fellow, Moffitt Cancer Center, Department of Cutaneous Oncology, 12902 Magnolia Drive, Mail Stop: Cut-Prog, Tampa, SRB4.24012, FL 33612, USA
| | - Georgia M Beasley
- Surgery Resident, Duke University Medical Center, Department of Surgery, Box 3118, Durham, NC 27710, USA
| | - Douglas S Tyler
- Professor of Surgery, Duke University Medical Center, Department of Surgery, Box 3118, Durham, NC 27710, USA
| | - Jonathan S Zager
- Associate Professor of Surgery, Moffitt Cancer Center, Department of Cutaneous Oncology, 12902 Magnolia Drive, Mail Stop: Cut-Prog, SRB4.24012, Tampa, FL 33612, USA
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Sanki A, Kroon HM, Kam PCA, Thompson JF. Isolated limb perfusion and isolated limb infusion for malignant lesions of the extremities. Curr Probl Surg 2011; 48:371-430. [PMID: 21549235 DOI: 10.1067/j.cpsurg.2011.02.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Amira Sanki
- Senior Registrar in Plastic and Reconstructive Surgery, Sydney, Australia
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Abstract
For in-transit melanoma confined to the extremities, regional chemotherapy in the form of hyperthermic isolated limb perfusion and isolated limb infusion are effective treatment modalities carrying superior response rates to current standard systemic therapy. Despite high response rates, most patients will eventually recur, supporting the role for novel research aimed at improving durable responses and minimizing toxicity. Although the standard cytotoxic agent for regional chemotherapy is melphalan, alternative agents such as temozolomide are currently being tested, with promising preliminary results. Current strategies for improving chemosensitivity to regional chemotherapy are aimed at overcoming classic resistance mechanisms such as drug metabolism and DNA repair, increasing drug delivery, inhibiting tumor-specific angiogenesis, and decreasing the apoptotic threshold of melanoma cells. Concurrent with development and testing of these agents, genomic profiling and biomolecular analysis of acquired tumor tissue may define patterns of tumor resistance and sensitivity from which personalized treatment may be tailored to optimize efficacy. In this article rational strategies for treatment of in-transit melanoma are outlined, with special emphasis on current translational and clinical research efforts.
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Padsis J, Turley R, Tyler D. Pharmacotherapy of regional melanoma therapy. Expert Opin Pharmacother 2009; 11:79-93. [DOI: 10.1517/14656560903428003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Beasley GM, Caudle A, Petersen RP, McMahon NS, Padussis J, Mosca PJ, Zager JS, Hochwald SN, Grobmyer SR, Delman KA, Andtbacka RH, Noyes RD, Kane JM, Seigler H, Pruitt SK, Ross MI, Tyler DS. A multi-institutional experience of isolated limb infusion: defining response and toxicity in the US. J Am Coll Surg 2009; 208:706-15; discussion 715-7. [PMID: 19476821 DOI: 10.1016/j.jamcollsurg.2008.12.019] [Citation(s) in RCA: 120] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2008] [Accepted: 12/02/2008] [Indexed: 12/22/2022]
Abstract
BACKGROUND Isolated limb infusion (ILI) is a minimally invasive approach for treating in-transit extremity melanoma, with only two US single-center studies reported. Establishing response and toxicity to ILI as compared with hyperthermic isolated limb perfusion is important for optimizing future regional chemotherapeutic strategies in melanoma. STUDY DESIGN Patient characteristics and procedural variables were collected retrospectively from 162 ILIs performed at 8 institutions (2001 to 2008) and compared using chi-square and Student's t-test. ILIs were performed for 30 minutes in patients with in-transit melanoma. Melphalan dose was corrected for ideal body weight (IBW) in 42% (n = 68) of procedures. Response was determined at 3 months by Response Evaluation Criteria in Solid Tumors; toxicity was assessed using the Wieberdink Limb Toxicity Scale. RESULTS In 128 evaluable patients, complete response rate was 31%, partial response rate was 33%, and there was no response in 36% of patients. For all patients (n = 162), 36% had Wieberdink toxicity grade >or=3 with one toxicity-related amputation. On multivariate analysis, smaller limb volumes were associated with better overall response (p = 0.021). Use of papaverine in the circuit to achieve cutaneous vasodilation was associated with better response (p < 0.001) but higher risk of grade >or=3 toxicity (p = 0.001). Correction of melphalan dose for ideal body weight did not alter complete response (p = 0.345), but did lead to marked reduction in toxicity (p < 0.001). CONCLUSIONS In the first multi-institutional analysis of ILI, a complete response rate of 31% was achieved with acceptable toxicity demonstrating this procedure to be a reasonable alternative to hyperthermic isolated limb perfusion in the management of advanced extremity melanoma.
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Affiliation(s)
- Georgia M Beasley
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
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Kroon HM, Moncrieff M, Kam PCA, Thompson JF. Factors Predictive of Acute Regional Toxicity After Isolated Limb Infusion with Melphalan and Actinomycin D in Melanoma Patients. Ann Surg Oncol 2009; 16:1184-92. [DOI: 10.1245/s10434-009-0323-x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2008] [Revised: 12/02/2008] [Accepted: 12/03/2008] [Indexed: 11/18/2022]
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McMahon N, Cheng TY, Beasley GM, Spasojevic I, Petros W, Augustine CK, Zipfel P, Padussis JC, Sanders G, Tyler DS. Optimizing melphalan pharmacokinetics in regional melanoma therapy: does correcting for ideal body weight alter regional response or toxicity? Ann Surg Oncol 2009; 16:953-61. [PMID: 19184236 DOI: 10.1245/s10434-008-0288-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2008] [Revised: 12/01/2008] [Accepted: 12/02/2008] [Indexed: 11/18/2022]
Abstract
BACKGROUND This study aims to determine what effect correcting melphalan dosing for ideal body weight (IBW) has on toxicity and response in isolated limb infusion (ILI) in patients with advanced extremity melanoma. METHODS This was an open observational study examining whether correcting the melphalan dose for IBW will influence response and toxicity in patients undergoing ILI for advanced extremity melanoma in 41 patients undergoing 42 procedures (13 without correction for IBW; and 29 with correction for IBW). Melphalan pharmacokinetics, limb toxicity, serologic toxicity, and response at 3 months were compared. RESULTS The corrected group had a lower estimated limb volume (V (esti)) to melphalan volume at steady state (V (ss)) (P < .0001) ratio as well as lower incidence of grade > or =3 regional toxicity, serologic toxicity, and compartment syndrome (P = .0249, P = .027, P = .02). There was a positive correlation of V (esti)/V (ss) to toxicity (P = .0127, r = .382). No significant difference in response (P = .3609) between the groups was found, although there was a trend of association between V (esti)/V (ss) and response (P = .051, r = .3383). CONCLUSIONS Correcting for IBW in ILI lowers toxicity without significantly altering response rates.
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Affiliation(s)
- N McMahon
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
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Current Clinical and Research Approaches to Optimizing Regional Chemotherapy: Novel Strategies Generated Through a Better Understanding of Drug Pharmacokinetics, Drug Resistance, and the Development of Clinically Relevant Animal Models. Surg Oncol Clin N Am 2008; 17:731-58, vii-viii. [DOI: 10.1016/j.soc.2008.04.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Kam PC, Thompson JF. Pharmacokinetics of Regional Therapy: Isolated Limb Infusion and Other Low Flow Techniques for Extremity Melanoma. Surg Oncol Clin N Am 2008; 17:795-804, ix. [DOI: 10.1016/j.soc.2008.04.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Padussis JC, Steerman SN, Tyler DS, Mosca PJ. Pharmacokinetics & drug resistance of melphalan in regional chemotherapy: ILP versus ILI. Int J Hyperthermia 2008; 24:239-49. [PMID: 18393002 DOI: 10.1080/02656730701816410] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Two forms of regional chemotherapy for the treatment of advanced melanoma or sarcoma of the extremity are isolated limb perfusion (ILP) and the more recently described isolated limb infusion (ILI). Melphalan is the most commonly employed agent in both ILP and ILI, although it is often used in conjunction with other cytotoxic and/or biologic therapies. While ILP and ILI are far more effective for the treatment of extremity disease than is systemic therapy, there is still significant room for improvement in outcomes, from the standpoint of both response rate and toxicity. An understanding of the pharmacokinetics of regional chemotherapy would allow for the prediction of tumor response and toxicity and therefore patient outcomes. In addition, elucidating the mechanisms of drug resistance would lead to opportunities to develop effective chemo-modulators that enhance the effectiveness of ILP and ILI. This paper reviews progress in these two key areas of active investigation.
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Affiliation(s)
- James C Padussis
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
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Grubbs EG, Ueno T, Abdel-Wahab O, Cheng TY, Pruitt SK, Michael Colvin O, Friedman HS, Tyler DS. Modulation of resistance to regional chemotherapy in the extremity melanoma model. Surgery 2004; 136:210-8. [PMID: 15300182 DOI: 10.1016/j.surg.2004.04.021] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The presence of resistance to chemotherapy is associated with poor tumor response and patient survival in a variety of tumors. Attempts to modulate resistance in conjunction with systemic chemotherapy have been limited by the toxicity of combined therapy, particularly gastrointestinal or hematopoetic toxicity. This study explored systemic modulation of resistance in conjunction with intra-arterial regional therapy to determine if tumor responses to melphalan could be improved with acceptable toxicity. METHODS Using a nude rat human xenograft model of extremity melanoma,we analyzed tumors for glutathione (GSH), the main protein in the melphalan resistance pathway. Modulation of GSH was performed with intraperitoneal buthionine sulfoximine (BSO). In parallel, BSO-modulated and nonmodulated animals underwent survival studies after regional intra-arterial perfusion with melphalan or saline. Rats were monitored daily for tumor growth and toxicity. RESULTS BSO depleted tumor GSH levels by 71.8% with minimal toxicity. Survival studies using increasing melphalan concentrations demonstrated similar tumor growth. The combined use of modulator and chemotherapeutic agent showed a significant tumor growth delay as compared to control and drug-alone group without enhanced toxicity. CONCLUSIONS Modulation of resistance in conjunction with regional chemotherapy allows for improved tumor responses with minimal toxicity. These results demonstrate that BSO can potentiate the cytotoxic effects of regional melphalan therapy in the setting of extremity melanoma.
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Affiliation(s)
- Elizabeth G Grubbs
- Departments of General Surgery, Internal Medicine, and Neurosurgery, Duke University Medical Center, Durham, NC 27710, USA
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Cheng TY, Grubbs E, Abdul-Wahab O, Leu SY, Hung CF, Petros W, Aloia T, Fedrau R, Pruitt S, Colvin M, Friedman H, Tyler D. Marked variability of melphalan plasma drug levels during regional hyperthermic isolated limb perfusion. Am J Surg 2003; 186:460-7. [PMID: 14599607 DOI: 10.1016/j.amjsurg.2003.07.019] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Hyperthermic isolated limb perfusion (HILP) with melphalan as treatment for locally recurrent or in-transit malignant melanoma is frequently performed but the principle for calculating drug dosage remains poorly understood. METHODS This study examined the pharmacokinetic profile of 14 consecutive patients to determine what variables were associated with toxicity and tumor responses. RESULTS Marked fourfold variability was noted in patient plasma melphalan concentrations. We defined a factor--the ratio of estimated limb volume (Vesti) to melphalan volume of distribution (Vss), Vesti/Vss--that was much more strongly correlated with acute regional toxicity than either area under concentration-time curve or peak plasma concentration. In addition, we found that AUX2 was the best correlate of tumor response. CONCLUSIONS Pharmacokinetic evaluation of prospective HILP trials is critical to not only understand response and toxicity outcomes but also to potentially improve the therapeutic index of regional perfusion.
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Affiliation(s)
- Tsung-Yen Cheng
- Department of Surgery, Box 3118, Duke University Medical Center, Durham, NC 27710, USA
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